BMC Public Health BioMed Central Research article Open Access Prevention of mother-to-child transmission of HIV in Zambia: implementing efficacious ARV regimens in primary health centers Justin Mandala*1, Kwasi Torpey2, Prisca Kasonde2, Mushota Kabaso2, Rebecca Dirks1, Chiho Suzuki1, Catherine Thompson2, Gloria Sangiwa1 and Ya Diul Mukadi1 Address: 1Family Health International (FHI), Public Health Programs, 4401 Wilson Blvd., Suite 700, Arlington, VA, 22203, USA and 2Zambia HIV/ AIDS Prevention, Care and Treatment Partnership (ZPCT), PO Box 320303, Woodlands, Lusaka, Zambia Email: Justin Mandala* - jmandala@fhi.org; Kwasi Torpey - ktorpey@zpct.org; Prisca Kasonde - pkasonde@zpct.org; Mushota Kabaso - mkabaso@zpct.org; Rebecca Dirks - rdirks@fhi.org; Chiho Suzuki - csuzuki@fhi.org; Catherine Thompson - cthompson@zpct.org; Gloria Sangiwa - gsangiwa@msh.org; Ya Diul Mukadi - mukadi@fhi.org * Corresponding author Published: 27 August 2009 Received: 4 May 2009 Accepted: 27 August 2009 BMC Public Health 2009, 9:314 doi:10.1186/1471-2458-9-314 This article is available from: http://www.biomedcentral.com/1471-2458/9/314 © 2009 Mandala et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Safety and effectiveness of efficacious antiretroviral (ARV) regimens beyond single-dose nevirapine (sdNVP) for prevention of mother-to-child transmission (PMTCT) have been demonstrated in well-controlled clinical studies or in secondary- and tertiary-level facilities in developing countries. This paper reports on implementation of and factors associated with efficacious ARV regimens among HIV-positive pregnant women attending antenatal clinics in primary health centers (PHCs) in Zambia. Methods: Blood sample taken for CD4 cell count, availability of CD4 count results, type of ARV prophylaxis for mothers, and additional PMTCT service data were collected for HIV-positive pregnant women and newborns who attended 60 PHCs between April 2007 and March 2008. Results: Of 14,815 HIV-positive pregnant women registered in the 60 PHCs, 2,528 (17.1%) had their CD4 cells counted; of those, 1,680 (66.5%) had CD4 count results available at PHCs; of those, 796 (47.4%) had CD4 count 350 cells/mm3 and thus were eligible for combination antiretroviral treatment (cART); and of those, 581 (73.0%) were initiated on cART. The proportion of HIV-positive pregnant women whose blood sample was collected for CD4 cell count was positively associated with (1) blood-draw for CD4 count occurring on the same day as determination of HIV-positive status; (2) CD4 results sent back to the health facilities within seven days; (3) facilities without providers trained to offer ART; and (4) urban location of PHC. Initiation of cART among HIV- positive pregnant women was associated with the PHC's capacity to provide care and antiretroviral treatment services. Overall, of the 14,815 HIV-positive pregnant women registered, 10,015 were initiated on any type of ARV regimen: 581 on cART, 3,041 on short course double ARV regimen, and 6,393 on sdNVP. Conclusion: Efficacious ARV regimens beyond sdNVP can be implemented in resource-constrained PHCs. The majority (73.0%) of women identified eligible for ART were initiated on cART; however, a minority (11.3%) of HIV-positive pregnant women were assessed for CD4 count and had their test results available. Factors associated with implementation of more efficacious ARV regimens include timing of blood-draw for CD4 count and capacity to initiate cART onsite where PMTCT services were being offered. Page 1 of 9 (page number not for citation purposes) BMC Public Health 2009, 9:314 http://www.biomedcentral.com/1471-2458/9/314 Background USAID-funded Zambia Prevention, Care, and Treatment Progress made in knowledge of HIV infection, and more Partnership (ZPCT). ZPCT, a partnership between Family particularly in the use of antiretrovirals (ARVs), has Health International (FHI) and the government of Zam- resulted in considerably reducing mother-to-child trans- bia, is supporting the Ministry of Health (MoH) to mission (MTCT) risk. Despite the increased availability of strengthen and expand existing HIV/AIDS services in five ARVs, an unacceptably high number of infants are being provinces: Northern, Luapula, Copperbelt, Central, and infected with HIV every year. In 2007 alone, 370,000 chil- North-Western. ZPCT implements activities within gov- dren were infected worldwide, 90% of them through ernment health facilities at primary through tertiary levels. MTCT and the majority in developing countries. [1] A typical ZPCT-supported PHC has no doctor and usually The World Health Organization (WHO) recommends use operates with a nurse. It may also have a clinical officer of efficacious ARV regimens beyond single dose nevirap- and a laboratory technician. PHCs with laboratory facili- ine (sdNVP). [2] HIV-positive pregnant women eligible ties usually offer basic laboratory services including full for antiretroviral treatment (ART) should be put on com- blood count, HIV testing, syphilis testing, and blood film bination antiretroviral treatment (cART), and those not for malaria. CD4 cell enumeration is normally under- eligible should be given a short course ARV prophylaxis. taken through a laboratory network, whereby blood sam- Single-dose nevirapine only is given to those identified ples from HIV-positive patients seen in PHCs are referred late in pregnancy or when the first two options are not fea- to larger health facilities for full blood count, including sible. WHO also recommends that all HIV-exposed CD4 cell count, using the FACScount flow cytometer (Bec- infants be given an appropriate ARV prophylaxis. ton Dickinson, San Jose, California, USA). Per national guidelines, all pregnant women that test HIV-positive The cornerstone in implementing efficacious ARV regi- should have a CD4 cell enumeration. Blood samples of mens is identification of HIV-positive pregnant women in HIV-positive pregnant women are collected either the need of cART for their own health. [2,3] In addition to same day or another day usually within a week of the clinical staging, eligibility for cART is based on absolute clinic visit, based on availability of transportation for CD4 cell count, which is often limited to secondary or ter- samples. Transporting samples to the referral lab and tiarylevel hospitals with capacity for immunological returning results to PHCs are coordinated by a laboratory screening. The majority of pregnant women in resource- technician. One referral lab serves an average of 5 to 10 limited settings seek antenatal and delivery care from PHCs. Turnaround time for CD4 count results to be midwives and nurses, most often in primary health cent- returned to PHCs is 7 to 30 days. ers (PHCs). These facilities have limited capacity to per- form CD4 count and identify women in need of cART, The Zambian National Guidelines for PMTCT, updated in making implementation of efficacious ARV regimens a 2007, promote the use of efficacious ARV regimens at all challenge. [4,5] health facilities, including PHCs. [12] Women eligible for cART are those with absolute CD4 count 350 cells/mm3 In developing countries, safety and effectiveness of effica- (regardless of clinical stage) and women in WHO clinical cious ARV regimens have been demonstrated in well-con- stage 4 (irrespective of absolute CD4 count). Interpreta- trolled clinical studies or in secondary and tertiary level tion of CD4 count and initiation of cART occurs in one of facilities. [6-10] However, large-scale implementation in three ways: (1) at a PMTCT site by a PMTCT provider, (2) PHCs in developing countries has not been widely at a PMTCT site by a mobile ART clinic team, or (3) at an described. The objective of this review is to determine the ART site following referral by a PMTCT provider. In the uptake of and factors associated with implementation of standard PMTCT package, women are encouraged to more efficacious ARV regimens (beyond sdNVP) for pre- deliver at health facilities. They are offered infant feeding vention of mother-to-child transmission of HIV (PMTCT) counseling, family planning counseling, and referral for among HIV-positive pregnant women in PHCs. comprehensive HIV clinical care, including cART if indi- cated. Context Zambia is a developing country in sub-Saharan Africa Methods with an adult HIV prevalence rate of 15.2%. [11] In 2007, Data Collection and Analysis an estimated 95,000 Zambian children under age 15 were This review is based on service data between April 2007 living with HIV. [11] Over 90% of pregnant women in and March 2008 from all 60 PHCs supported by ZPCT, 24 Zambia seek antenatal care. [4,5] in rural and 36 in urban areas in five provinces (Central, Copperbelt, Luapula, Northern and North-Western), with Zambia has been implementing PMTCT programs since a total catchment population of 1,451,260. Aggregated 1999 with support of several donors, including the quarterly data by site were collected on number of: 1) Page 2 of 9 (page number not for citation purposes) BMC Public Health 2009, 9:314 http://www.biomedcentral.com/1471-2458/9/314 HIV-positive pregnant women, 2) HIV-positive pregnant (47.4%) had CD4 count 350 cells/mm3 and thus were women assessed for CD4 count, 3) HIV-positive pregnant eligible for cART; and of those, 581 (73.0%) were initiated women with CD4 cell count available at PHC, 4) HIV- on cART (Figure 1). Among available CD4 count results, positive pregnant women initiated on cART, 5) HIV-posi- the median CD4 count was 366 cells/mm3, a finding con- tive pregnant women initiated on short course ARV, 6) sistent with other studies in similar resource-limited con- HIV-positive pregnant women given sdNVP, and 7) texts. [7,13,14] exposed infants who received an ARV prophylaxis. Uptake of CD4 count assesment and cART initiation over Additional data collected by site included availability of time same-day blood collection for CD4 count enumeration, Across the 12 months of observation, there was an number of days for return of CD4 count results, whether increase in the proportion of HIV-positive pregnant ART-trained staff are on site, and place of initiation of women assessed for CD4 count, the proportion of CD4 cART (on or off PMTCT site), and location of the PHC count results available at PHCs, and the proportion of (urban or rural). HIV-positive women eligible for treatment who initiated cART (Figure 2). During the first quarter, 12.2% of HIV- Data were extracted from MoH-mandated PMTCT log- positive pregnant women (95% confidence interval [CI], books in PHCs. A workshop with ZPCT staff from the five 11.2%13.2%) were checked for CD4 count; during the provinces was conducted to develop tools to aggregate fourth quarter, 24.5% (95% CI, 23.1%25.9%) were data from the logbooks. When finalizing the data collec- assessed (p < 0.001). Similarly, during the first quarter, tion tools, staff suggested that a page be added to the tools the CD4 count results of 7.2% of HIV-positive pregnant to capture any additional comments that PMTCT service women (95% CI, 6.5%8.0%) were available at clinics providers wished to share. compared to 16.8% (95% CI, 15.6%18.1%) during the fourth quarter (p < 0.001). Lastly, during the first quarter, Data analysis was performed using Epi Info 3.3.2 for Win- 2.6% of all HIV-positive pregnant women (95% CI, dows and Stata SE Version 9.0 (College Station, TX). Chi- 2.1%3.1%) received cART compared to 5.5% (95% CI, squares with 95% confidence intervals were used to com- 4.8%6.3%) during the fourth quarter (p < 0.001). pare proportions of uptakes among the following inde- pendent variables: (1) sites providing same-day blood a For all %, the denominator used the total number of draw for CD4 count enumeration compared to those pro- pregnant women tested HIV+ for each corresponding viding blood draw in a subsequent visit, (2) sites provid- period ing CD4 count results within seven days compared to those providing results in eight or more days, (3) sites Factors associated with uptake of CD4 count assessment with ART-trained staff compared to sites without, and (4) and cART initiation urban versus rural location of PHC. Multivariate regres- The uptake of CD4 cell enumeration among HIV-positive sion was used to analyze the association between the pregnant women was positively associated with several dependent variable as measured in proportions of HIV- health system factors: (1) blood-draw for CD4 count positive pregnant women assessed for CD4 count, and occurring on the same day as determination of HIV-posi- independent variables listed above. Chi-squares with 95% tive status, (2) CD4 count results sent back to the health confidence intervals were also used to compare uptakes facilities within seven days, (3) facilities without providers between the first quarter (April to June 2007) and fourth trained to offer ART, and (4) health facility being located quarter (January to March 2008). in an urban area (Table 1). The result of the multivariate regression analysis showed that same-day blood sample Ethical considerations for CD4 count and urban location of a PHC are positively The review was submitted to FHI's Protection of Human associated (results not shown, p < 0.001) with the propor- Subjects Committee and received exemption as it exam- tion of women assessed for CD4, after accounting for the ined routinely collected, aggregated program data. effects of the two other variables (CD4 count results avail- able within seven days and facilities without trained ART Results providers). Overall uptake of CD4 count assessment and cART initiation Data supported the association between initiation of cART Between April 2007 and March 2008, 14,815 HIV-positive among HIV-positive pregnant women with the capacity of pregnant women were registered in the 60 PHCs. Of those PHCs to provide HIV/AIDS care and treatment services on women, 2,528 (17.1%) had their blood sample collected site (Table 1). A higher proportion of women seen at for CD4 count assessment; of those, 1,680 (66.5%) had PMTCT sites with the capacity to provide HIV/AIDS care CD4 count results available at PHCs; of those, 796 and treatment were initiated on cART relative to those Page 3 of 9 (page number not for citation purposes) BMC Public Health 2009, 9:314 http://www.biomedcentral.com/1471-2458/9/314                  !" #"#$ !" (" )* !" %) !" (((    % &' +(*,* *((,* % # -! # -!         AFitgtruitrieo n1 cascade in implementing efficacious ARV regimens in PHC Attrition cascade in implementing efficacious ARV regimens in PHC. seen at PMTCT sites without HIV/AIDS care and treatment fourth quarter (p < 0.001). Though the sdNVP-only regi- capacity. Of the 326 women seen in PMTCT sites with men was used most frequently, its use decreased from capacity to provide HIV/AIDS care and treatment, 319 or 67.2% to 59.7% between the first and fourth quarters. The 97.9% (95% CI, 96.3%99.4%) were initiated on cART, use of AZT+sdNVP and cART regimens increased from while of the 470 eligible women seen in PMTCT sites 27.5% to 33.2% and 5.3% to 7.1% between the first and without HIV/AIDS care and ART capacity, 262 or 55.7% fourth quarters, respectively (Figure 3). The uptake of ARV (95% CI, 51.2%60.2%) were initiated on cART (p < prophylaxis among HIV-exposed children remained near 0.001). 23% across the period of observation. Uptake of ARV regimens over time Discussion Of the 14,815 HIV-positive pregnant women registered, This review demonstrated that implementation of effica- 10,015 (67.6%) were initiated on any type of ARV regi- cious ARV regimens for PMTCT is possible in PHCs in men: 581 on cART, 3,041 on short-course, double-ARV resource-constrained settings. However, it also high- regimen, and 6,393 on sdNVP only (Figure 1). Also, 3,463 lighted three key bottlenecks in implementing efficacious infants (23.4% of all HIV-exposed newborns) were initi- ARV regimens: (1) capacity to assess CD4 count, (2) avail- ated on ARV prophylaxis. ability of CD4 count results at clinics, and (3) capacity to initiate cART. The uptake of any ARV regimen among HIV-positive preg- nant women increased over time: 48.8% (95% CI, Most worrisome if the fact that nearly 83% of HIV-posi- 47.3%50.2%) of HIV-positive pregnant women were tive pregnant women did not have their blood collected being initiated on any ARV regimen during the first quar- for CD4 cell enumeration. This major gap can be ter compared to 77.9% (95% CI, 76.6%79.3%) during the explained by the non-systematization of same-day blood Page 4 of 9 (page number not for citation purposes) BMC Public Health 2009, 9:314 http://www.biomedcentral.com/1471-2458/9/314 ./ 01 3 ./ 0123 ./ 013 .2/ 013 2.2/ ./ 013 0123 . / 013  ./   012 3     ./  01 3./ 2./ 013 ./ 013 013  4)  4)*6 7   8# '#  4   512 51 2  512 512   ! " !#$#%"#&" '"%(%&" ) * +% %#  ) * FCiDgu4 rceo u2nt uptake, availability of results at clinics, and cART initiation over time CD4 count uptake, availability of results at clinics, and cART initiation over time. collection for CD4 count along with other probable be HIV-positive, may be reluctant to be seen in the same causes found in providers' comments such as (1) limited waiting area with HIV/AIDS patients. In PHCs providing sensitization for beneficiaries and providers on the impor- ART on site, there is usually a separate structure and/or tance of efficacious ARV regimens, and (2) a client flow waiting area specific to HIV/AIDS services. On the other that continues to adjust to this relatively new interven- hand, at PHCs that do not provide ART onsite, women tion. Other comments of PMTCT providers suggest that provide blood samples in the antenatal setting of PHCs stigma may prevent women from providing a blood sam- and are therefore more likely to provide a sample (Table ple for CD4 cell enumeration in an HIV/AIDS care and 1). treatment setting. Pregnant women, when determined to Table 1: Percentage of women checked for CD4 count by type of PHC In PHCs WITH same day blood-draw for CD4 check In PHCs WITHOUT same day blood-draw for CD4 check? P < 0.001 (n = 6,830) (n = 7,985) 18.4% [95% CI, 17.5% 19.3%] 15.9% [95% CI, 15.1% 16.7%] In PHCs where CD4 results are back WITHIN 7 days In PHCs where CD4 results are back MORE THAN 7 days P = 0.003 (n = 12,499) after (n = 2,316) 17.5% [95% CI, 16.8% 18.1%] 14.9% [95% CI, 13.5% 16.4%] In PHCs WITH onsite initiation of ART In PHC WITHOUT onsite initiation of ART P < 0.001 (n = 5,985) (n = 8,830) 13.7% [95% CI, 12.9% 14.6%] 19.3% [95% CI, 18.5% 20.1%] In PHCs located in urban areas In PHC located in rural areas P < 0.001 (n = 10,252) (n = 4,563) 21.4% [95% CI, 20.7% 22.2%] 7.2% [95% CI, 6.5% 8.0%] Page 5 of 9 (page number not for citation purposes) BMC Public Health 2009, 9:314 http://www.biomedcentral.com/1471-2458/9/314 100% 90.0%  ./ ./ 2./ . / 0123 013 013 013 90% 80.0%      80%     70.0%   70% 60.0% 60%    50.0%   50% 40.0% 40% 30.0% 30% 20.0% 20% 22./  ./ 2././ 013 013 013013 10.0% 10% .2/ ./ .2/ ./ 013 013 013 01 3 0% 0.0%  4)  4)*6 7   8# '#  4   %$%() * %$%(),*-!./0 %$%(!./0 "1 2 # #1) /%3  ! DFiigsturribeu 3tion of regimens used and overall uptake of ARV regimens among women Distribution of regimens used and overall uptake of ARV regimens among women. The second major bottleneck was the receipt of CD4 count The third bottleneck was observed at initiation of cART. results by PHCs. Test results of 33.5% of blood samples We found that 27% of women determined to be eligible collected for CD4 cell enumeration were never returned to did not initiate treatment (Figure 1). Barriers suggested in the clinic (Figure 1). Possible reasons mentioned in the the comments from providers include the limited capacity one-page comment form include a lack of coordination of of PHCs to offer HIV/AIDS care and treatment onsite and identification numbers between PHCs and laboratories, lack of training and sensitization among healthcare pro- limited efficiency of the sample referral network, frequent viders on implementation of a more efficacious ARV regi- breakdown of CD4 count machines, insufficient number men. of trained laboratory technicians to run CD4 count labo- ratory equipment, lab fees applied in some facilities for Among HIV-positive women whose CD4 count results CD4 count, and clerical errors. were available, 47% were eligible for cART. When that per- centage (47%) is applied to the 13,135 HIV-positive preg- nant women who failed to be assessed for CD4 count, we Page 6 of 9 (page number not for citation purposes) !6  % - (    " ((( 6 -  BMC Public Health 2009, 9:314 http://www.biomedcentral.com/1471-2458/9/314 estimate that 6,173 HIV-positive pregnant women who networks for blood-sample transportation and communi- were eligible failed to be initiated on cART. The MTCT rate cation of test results; and (3) strengthening the capacity of is 7% in mothers with indication for lifelong ART that laboratories to perform CD4 cell enumeration with point- receive cART, compared to 26% in HIV-positive pregnant of-care (POC) CD4 count testing. [16-20] women with indication for lifelong ART that received a short-course ARV regimen. [7,8] We therefore estimate POC CD4 count testing may mitigate the limited capacity that 1,173 pediatric HIV infections failed to be prevented of laboratories and inconsistent sample referral networks. because CD4 cell counts were not available for HIV-posi- Using POC CD4 count testing, PHCs can operate with tive pregnant women. more flexibility to organize same-day blood-draw for pregnant women determined to be HIV-positive. How- Among HIV-positive pregnant women that accessed ARVs ever, the POC CD4 approach has drawbacks: cost per CD4 for PMTCT, the proportion of those initiated on cART count test is higher, quality assurance in testing is more increased from 5.3% the first quarter to 7.1% the fourth difficult to ensure, and already stretched human resource, quarter (Figure 3). These proportions, although encourag- logistics, and supply chain management of PHCs would ing, remain low compared to global data. UNICEF and be further burdened. [16] While the current approacha WHO reported that in 2007, among HIV-positive women central laboratory and network of PHCs referring sample- that accessed ARV for PMTCT, 9.0% were initiated on life- sis not optimal, establishing several CD4 count POC hubs long cART. [15] Moreover, a Rwandan study reported a that cover a smaller number of PHCs may be an alterna- 16.0% proportion of cART among all PMTCT ARV regimes tive. from health centers and district hospitals. [10] The differ- ences in proportions initiating cART between our review To improve implementation of efficacious PMTCT ARV and the UNICEF/WHO report and the Rwanda study may regimens, PHCs should also maximize initiation of cART be due to several factors: (1) our review included data at PMTCT sites: PMTCT providers should be able to assess only from PHCs and did not include district hospitals; (2) eligibility for lifelong ART and initiate cART. This unlike Rwanda PMTCT sites, ZPCT-supported sites do not approach requires intensive training and mentoring and physically escort HIV-positive pregnant women to ART should be balanced with the already heavy workload of clinics; and (3) implementation of efficacious (and com- healthcare providers in antenatal clinic (ANC) settings. plex) ARV regimens were being rolled out in ZPCT-sup- Given the human resource shortages experienced by most ported sites during the period of review. [Personal developing countries, increasing the number of providers communication with K. Torpey, 2009] at PHCs may not be feasible. The increasing trend in uptake of CD4 count assessment, Another option may be to schedule regular mobile ART availability of results at clinics, and cART initiation among clinics visits at antenatal clinics on designated maternal HIV-positive pregnant women as well as the increase in and child health days. the overall uptake of ARV regimes are more likely related to the continuous technical support that ZPCT provided One major limitation of this review is that only CD4 [Personal communication with K Torpey, 2009]. ZPCT's count (CD4 350 cells/mm3 as per the national recom- technical support consisted of training on the implemen- mendations) was considered as the criteria to initiate tation of the efficacious PMTCT regimen and continuous cART. Although clinical staging is another important crite- mentoring of healthcare providers. For example, the refer- rion, no related data were available. Additionally, analysis ral network was reinforced through provision of motor- by age was not possible since tools developed for this bikes to transport blood samples and establishment of a review only captured aggregated data. referral coordinator in each laboratory. Additionally, patient flow was optimized to reduce client waiting time, Another limitation is that reporting on "uptake of ARVs" and the capacity of PHCs to initiate cART (whether on site, refers only to dispensation of ARV drugs and not adher- through ART mobile clinics, or through referral) was ence to the dispensed drugs. Data to ascertain adherence increased through cART training. to dispensed ARV drugs was unavailable. In similar resource-limited settings, self-reported adherence to ARVs The key to improving implementation of more efficacious among pregnant women accessing PMTCT ranged ARV regimens for PMTCT in PHCs lies in building the between 90% and 95%. [21-24] However, a study con- capacity to determine CD4 cell count. Looking forward, ducted in Zambia that measured the presence of NVP in several approaches may be used to improve this capacity the cord blood of women that accessed PMTCT found an in PHCs: (1) providing same-day blood-draw for CD4 cell actual adherence rate of only 68%. [25] In addition, stud- enumeration, which requires coordination between ante- ies in Kenya and Zambia found that women delivering at natal and laboratory departments; (2) building reliable home were two to three times more likely to be non- Page 7 of 9 (page number not for citation purposes) BMC Public Health 2009, 9:314 http://www.biomedcentral.com/1471-2458/9/314 adherent. Given that more than 50% of women deliver at 5. World Health Organization: World Health Statistics 2008 Geneva, home in Zambia, non-adherence could be a major issue. Switzerland: WHO; 2008. 6. Marazzi MC, Germano P, Liotta G, Guidotti G, Loureiro S, da Cruz [9,11,22] Adherence to complex ARV regimens remains Gomes A, Valls Blazquez MC, Narciso P, Perno CF, Mancinelli S, Pal- mostly unknown. ombi L: Safety of nevirapine-containing antiretroviral triple therapy regimens to prevent vertical transmission in an Afri- can cohort of HIV-1-infected pregnant women. HIV Medicine Conclusion 2006, 7:338-344. The review revealed that implementation of efficacious 7. Tonwe-Gold B, Ekouevi DK, Viho I, Amani-Bosse C, Toure S, Coffie PA, Rouet F, Becquet R, Leroy V, El-Sadr WM, Abrams EJ, Dabis F: ARV regimes for PMTCT is possible in PHC in resource- Antiretroviral treatment and prevention of peripartum and constrained settings. The majority of women identified postnatal HIV transmission in West Africa: evaluation of a eligible for ART were initiated on cART; however, only a two-tiered approach. PLoS Medicine 2007, 4:e257.8. Leroy V, Ekouevi DK, Dequae-Merchadou L, Viho I, Becquet R, minority of HIV-positive pregnant women were assessed Tonwe-Gold B, Rouet F, Horo A, Sakarovitch C, Timité-Konan M, for CD4 count and had their test results available. Factors Dabis F, Toni T, DITRAME PLUS ANRS 1201/1202 Study Group: 18- month effectiveness of short-course perinatal antiretroviral associated with implementation of more efficacious ARV regimens combined to infant-feeding interventions for regimens included timing of blood-draw for CD4 count PMTCT in Abidjan, Côte d'Ivoire [Abstract no. THAC010]. and capacity to initiate cART onsite where PMTCT services 16th International AIDS Conference; 1318 August 2006; Toronto, Canada .9. Black V, Hoffman RM, Sugar CA, Menon P, Venter F, Currier JS, Rees were being offered. In order to improve implementation, H: Safety and efficacy of initiating highly active antiretroviral multiple obstacles at the health system level should be therapy in an integrated antenatal and HIV clinic in Johan- addressed. Additional organizational and programmatic nesburg, South Africa. J Acquir Immune Defic Syndr 2008,49:276-281. research should examine the causes and potential solu- 10. Tsague L, Tene G, Adje-Toure C, Koblavi S, Mugisha V, Rubin J, tions to bottlenecks. Further research should also be con- Vandebriel G, Sahabo R, Tsiouris F, Abrams E: Rapid implementa- tion of more efficacious antiretroviral regimens for the pre- ducted to ascertain adherence rates of HIV-positive vention of mother-to-child transmission (PMTCT) of HIV in pregnant women to complex ARV regimens. Rwanda [Poster 830]. 15th Conference on Retroviruses and Oppor- tunistic Infections: 36 February 2008; Boston, MA . 11. World Health Organization and Joint United Nations Programme on Competing interests HIV/AIDS: Epidemiological Fact Sheet on HIV and AIDS: Core data on epi- The authors declare that they have no competing interests. demiology and response, Zambia. 2008 Update [http://www.who.int/ globalatlas/predefinedReports/EFS2008/full/EFS2008_ZM.pdf]. Last accessed April 24, 2009 Authors' contributions 12. Ministry of Health: National Protocol Guidelines: Integrated Prevention of JM, KT, and GS conceived of the study. JM, KT, MK, PK, Mother to Child Transmission of HIV Lusaka, Zambia: Ministry of Health;2007. RD, and CS participated in the design. MK and RD coor- 13. Stringer JS, Sinkala M, Goldenberg RL, Kumwenda R, Acosta EP, dinated data collection. Statistical analysis was performed Aldrovandi GM, Stout JP, Vermund SH: Universal nevirapine upon by CS, JM, MK, and YDM. JM and RD drafted the manu- presentation in labor to prevent mother-to-child HIV trans-mission in high-prevalence settings. AIDS 2004, 18:939-9423. script. Critical review of the manuscript was provided by 14. Dabis F, Leroy V, Bequet L, Ekouevi DK, Viho I, Horo A, Timite- YDM, GS, CT, KT, JM, RD, PK, CS, and MK. All authors Konan M, Welffens-Ekra C: Effectiveness of a short course of zidovudine + nevirapine to prevent mother-to-child trans- read and approved the final manuscript. mission (PMTCT) of HIV-1: The Ditrame Plus ANRS 1201 Project in Abidjan, Côte d'Ivoire [Abstract no. ThOrD1428]. Acknowledgements 14th International AIDS Conference: 712 July 2002; Barcelona, Spain .15. United Nations Children's Fund, Joint United Nations Programme on The authors would like to express their appreciation to all ZPCT and clin- HIV/AIDS, World Health Organization: Towards Universal Access, Scal- ical staff whose efforts made this article possible. We wish to also acknowl- ing up HIV Services for Women and Children in the Health Sector: Progress edge the support of the Zambia Ministry of Health. 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